MINOR PATIENT CONSENT FOR ORTHODONTIC TREATMENTIN THE ABSENCE OF A PARENT OR LEGAL GUARDIAN
Patient Full Name
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First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Authorization
I authorize Johnson Orthodontics to perform routine orthodontic procedures and adjustments that are part of my child's established treatment plan when I am not present. I understand that a summary of my child's orthodontic appointment and any instructions orrecommendations will be communicated to me through the practice’s customary methods ofcommunication (text or email) and that I am responsible for reviewing the summary andcontacting the office with any questions or concerns.
YES, my child may attend orthodontic appointments without a parent/legal guardianpresent.
NO, my child may not attend orthodontic appointments without a parent/legal guardian present.
Parent/Legal Guardian Name
First Name
Last Name
Date
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Month
-
Day
Year
Date
Signature
*
This authorization shall remain in effect until revoked in writing by me, until the patient reaches 18 yearsof age, or until active orthodontic treatment is completed, whichever occurs first.
Submit
Submit
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